Health Equity

Social Justice Usage

Source: Braveman, Paula A. Braveman, Shiriki Kumanyika, Jonathan Fielding, et al. “Health Disparities and Health Equity: The Issue Is Justice.” American Journal of Public Health 101(51): 2011.

Health equity is the value underlying a commitment to reduce and ultimately eliminate health disparities. It is explicitly mentioned in the Healthy People 2020 objectives. Health equity means social justice with respect to health and reflects the ethical and human rights concerns articulated previously. Health equity means striving to equalize opportunities to be healthy. In accord with the other ethical principles of beneficence (doing good) and nonmalfeasance (doing no harm), equity requires concerted effort to achieve more rapid improvements among those who were worse off to start, within an overall strategy to improve everyone’s health. Closing health gaps by worsening advantaged groups’ health is not a way to achieve equity. Reductions in health disparities (by improving the health of the socially disadvantaged) are the metric by which progress toward health equity is measured.

New Discourses Commentary

Health equity is, like many concepts that appear within Critical Social Justice, one that can be understood in more reasonable and broader terms and yet has to be understood simultaneously in narrower, more specific terms used by activists who are pushing Critical Social Justice agendas and thinking (see also, critical consciousness and wokeness). Not unlike the move from the study of climate change to an emphasis on climate justice, which makes the issue of climate center Critical Social Justice and its agendas (say, instead of science), bringing the whole topic under the purview of its Theory, health equity is used to bring Critical Social Justice into medicine and public health. The goal of health equity is to apply the concept of equity to health (see also, equality), which means attempting to create equality of outcomes in healthcare and public health through sociological change (up to and including revolution upon the current health and sociopolitical systems).

Health equity is, obviously, the application of “equity” to systems of health and healthcare. Equity refers to the idea of adjusting shares so as to make citizens equal to one another (i.e., creating approximate equality of outcomes), and thus health equity usually refers to the idea of adjusting various social systems to reduce disparities in health-based outcomes for different populations in a stratified society (that is, in a society where people aren’t all equal). This can and usually does involve attempting to improve access to health-relevant resources, particularly for poor people, and combating attitudes within various groups that might limit their willingness to access healthcare or trust doctors. Making healthcare more affordable for financially vulnerable people would therefore fall under the heading of health equity in a way that currently relatively few people in modern liberal societies disagree with.

As can be read above, health equity is to be determined like in nearly all equity programs—by the existence of health gaps across matters of economics (more traditionally and under progressive liberalism) and/or identity (more intersectionally). In the broadest understanding, the idea of health equity is both good and consistent with liberal ethics; it is the aim to make healthcare systems more fair, as can be determined by looking at the ways social inequalities (e.g., poverty) can lead to disparities in average health outcomes. Depending upon the theory of justice under consideration, this can take a wide variety of forms. These different theories of justice and different approaches appear in different approaches to the subject across the existing literature. This has the benefit of making the topic more reasonable—not merely a bugbear that needs to be criticized and avoided—and the cost of making critical approaches, specifically Critical Social Justice approaches appear more rigorous and valuable than they are. This entry will primarily focus upon the Critical Social Justice approaches.

The most extreme and alarming understanding of health equity, which occasionally appears within the Critical Social Justice concept of it, would effect equity programs based on identity politics at the point of healthcare delivery. This would include providing preferential care to members of minoritized groups while restricting or limiting care for members of dominant groups, as determined by Theory (see also, progressive stack). This approach is occasionally advocated and a potential risk of taking on a sweeping Critical Social Justice program within healthcare, but it is not the leading conception of health equity even within Critical Social Justice. Generally, in fact, it is often, but not always, specifically rebuked as falling outside of the “nonmalfeasance (do no harm)” mission of medicine. In that sense, this facile and direct approach to health equity should be seen as the bottom of a potentially slippery slope where Critical Social Justice approaches to health equity are concerned.

More likely measures to be seen at the level of point-of-delivery in health equity programs would be encouraging cultural/racial humility/sensitivity, intersectional feminism, diversity, equity, and inclusion training, implicit bias training, and otherwise attempting to make medical professionals and the cultures and spaces in which they work generally more woke (or, perhaps, to decolonize healthcare, in more extreme cases). These would seek to remake the culture within healthcare, consistent with the Critical Social Justice program. This would also tend to implement the broad Critical Social Justice goal of making everything in society concerned with identity politics. Another possibility might include including broader ranges of medical approaches (see also, racial knowledge, knowledge(s), and ways of knowing) and ensuring a diverse medical workforce so that patients can have medical professionals of the same identity as they are (see also, linguistic justice).

Typically, Critical Social Justice does not take this direct and facile (and alarming) approach to health equity. Instead, it does what it always does and considers society itself as well as our institutions of healthcare and public health and looks for the ways that various systemic power dynamics play a role in creating disparities in health outcomes. This would be reasonable enough if it weren’t taken up in the manner of Critical Social Justice (thus making valid and important criticisms of unrealistic or unreasonable health equity programs even more difficult), which takes the existence of any disparities whatsoever as evidence of the necessarily unjust systems of “dominance and oppression,” that it Theorizes into existence as the only possible explanatory mechanism for any disparity (while bullying other potential explanations off the table, perhaps as forms of “cultural racism” or “responsibilization.”) Health equity would be very concerned with the ways oppression is perpetuated and effected within domains of health and would seek systemic change to make that no longer the case, as measured by any disparities in outcome and assessed by Theory.

This is because Critical Social Justice always and only thinks in terms of systemic injustices that come about through socialization by society into an order that legitimizes and maintains dominance (see also, hegemony, ideology, and internalized dominance), thus oppression and marginalization of those excluded from dominant groups (see also, minoritze). As applied to health equity, as can be read below, “inequities are a product of social processes and are potentially remedial through attention to social processes.” It is these social processes—sometimes described more bluntly as “the fabric of society”—that Critical Social Justice is always interested in disrupting, dismantling, and remaking in its own image. In particular, Critical Social Justice would approach health equity by trying to change the patterns of socialization both within healthcare and public health and throughout broader society by making everyone think the way it thinks about these issues.

Of some importance, Critical Social Justice thinks about issues in this way in part because of its wholly socially constructivist stance. Under Critical Social Justice, all (or most, in more reasonable activists) differences are matters of social constructions around matters of identity and the ways that society is socialized to treat people in different social positions differently. Thinking of this kind is already standard in fat activism, which sees obesity and the concept of being overweight as nothing more than harmful social constructions that create and maintain fatphobia (see also, narrative, regulatory fiction, fat studies, and body positivity). Though other possibilities exist (e.g., ignoring the realities that different human populations have different susceptibilities to certain diseases and disorders), this will have the most relevance to medicine under the influences of queer Theory, which will insist that the underlying biology of an individual is largely or totally irrelevant to their gender identity, which will be extended to include their sex identity as well (see also, biological essentialism, sex essentialism, blank slatism, and trans rights activism).

A real-world example of this kind of health-equitable thinking arose during the Covid-19 pandemic in early 2020, when transition surgeries were deemed “non-essential” under pandemic triage in a popular article published in Vice, though this is merely the tip of that iceberg. Other examples of the kind would include pressuring healthcare professionals into gender-affirming practices and surgeries in cases where they might not be the best course of care and into ignoring biological realities of their patients. Ignoring and denying the relevance of biology in the field of medicine is, it seems, unlikely to improve health outcomes and thus likely to backfire upon the activists in the very causes they push this type of thinking into.

As a final and elucidating point on the big picture, the goal of Critical Social Justice approaches to health equity is not usually necessarily to change access to care at the point of delivery, which it would see as a low-level but potentially useful project, at best, but instead to use inequalities (or, as it has them, “inequities”) in health outcomes as a lever to justify trying to remake the system itself (see also, revolution). That is, health equity under Critical Social Justice is mostly a rhetorical stance that uses legitimate issues in public health and healthcare as means to push its radical sociopolitical agenda. It does this specifically by trying to cast any disparities as the result of institutional racism, mostly to justify changes in policy. Usually, societal change according to its designs is a higher-order goal of Critical Social Justice than merely changing circumstances at the point of delivery, though it will rely upon those methods as well (as happens widely and routinely already in equity-in-education programs). Thus, much like the situation with climate justice, health equity under the auspices of Critical Social Justice is mostly a means to take an important publicly relevant issue and use it to lobby further for its radical political agenda for sweeping social change, most importantly at the level of changing policy or law to enact its vision and force society to comply.

See also – equity, cf. equality.

Related Terms

Biological essentialism; Blank slatism; Body positivity; Center; Climate justice; Critical; Critical consciousness; Cultural humility; Cultural racism; Cultural sensitivity; Decolonize; Dismantle; Disrupt; Diversity; Dominance; Equality; Equity; Exclude; Fat activism; Fat studies; Fatphobia; Feminism; Gender; Gender-affirming; Gender identity; Harm; Hegemony; Ideology; Identity; Identity politics; Implicit bias; Inclusion; Injustice; Internalized dominance; Intersectionality; Justice; Knowledge(s); Legitimate; Liberalism; Linguistic justice; Marginalization; Minoritize; Narrative; Oppression; Position; Progressive; Progressive stack; Queer Theory; Racial humility; Racial knowledge; Radical; Regulatory fiction; Responsibilization; Revolution; Science; Sex; Sex essentialism; Space; Social construction; Social constructivism; Social Justice; Socialization; System, the; Systemic power; Theory; Trans rights activism; Ways of knowing; Woke/Wokeness

Additional Examples

Source: Pauly, B. M., MacKinnon, K., & Varcoe, C. “Revisiting ‘Who Gets Care?’” Advances in Nursing Science 32(2): 2009, 118–127, pp. 118–119.

Sherwin, a leading feminist scholar, argues that oppressive social conditions, such as racism, sexism, and classism, that shape access to healthcare are the same conditions that shape inequities in health with poverty being a major determinant of poor health. In this article, we will begin with a discussion of health inequities and the conditions that shape inequities. We propose that nurses need a conceptual understanding of social justice that is consistent with addressing the conditions that shape inequities in healthcare. We provide an overview of dominant conceptions of justice and propose an alternative conceptualization of social justice for nursing to address inequities that draws on Iris Marion Young’s work. Finally, we highlight nursing actions for addressing conditions that impact access to healthcare and those institutional factors that produce health inequities.

Equity refers to fairness or justice and can be understood as equity in access to healthcare and equity in health outcomes. Inequities are unfair or unjust differences in access to services or health outcomes that result from structural arrangements that are potentially remedial. Whitehead and Dahlgren have suggested that inequities in health can be identified on the basis of 3 distinguishing features. First, health inequities “concern systematic differences in health status between different socioeconomic groups.”(p2) Second, inequities are a product of social processes and are potentially remedial through attention to social processes. Third, inequities are the consequence of “unjust social arrangements”or social structures that perpetuate these differences.

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Source: Pauly, B. M., MacKinnon, K., & Varcoe, C. “Revisiting ‘Who Gets Care?’” Advances in Nursing Science 32(2): 2009, 118–127, p. 119.

If we wish to effect equity of access, then attention is required to structural injustices that act as barriers to healthcare services such as addressing the stigma and discrimination experienced when accessing healthcare services by those disadvantaged by their social positioning in relation to class, gender, ethnicity, and so on.

McGibbon et al propose that

Access refers not only to the availability of required services but also to how the services are delivered at point of care (e.g., cultural competence of health-care providers). These inequities play an important role in creating poorer health outcomes.(p24)

The conditions that structure access to health services for groups identified as vulnerable or disadvantaged are critical to our understanding of health inequities and social justice. We concur with Drevdahl et al that inequities cannot be addressed through practicing with cultural competence at the individual level; rather, racism and other marginalizing discourses that reduce access to care need to be addressed.

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Source: Pauly, B. M., MacKinnon, K., & Varcoe, C. “Revisiting ‘Who Gets Care?’” Advances in Nursing Science 32(2): 2009, 118–127, p. 120.

Effecting health equity would look to those broader conditions that produce health inequities such as poverty, inadequate housing, racializing structures, criminalization of drug use, social exclusion, and violence. Income inequality in terms of relative rather than absolute differences contributes to the development of health inequalities. For example, those who are at the highest risk for food insecurity and inadequate housing are those who live in relative poverty. It is these determinants of inequities that have the potential to affect health equity and decrease gaps in health outcomes between groups in society. In particular, it is the intersection of gender, race, and class in relation to the determinants of health that produce profound inequities. Thus, beyond examining how healthcare is provided we need to examine the ways that society is organized and the structural conditions that contribute to vulnerability, illness, and injury for groups in the population. …

Inequities in access to material resources (including access to health services) interact with the person’s environment in ways that contribute to inequities in health outcomes. Gendered, racialized, and socioeconomic differences produce health inequities. Further examination of social processes (including discourses activated by healthcare providers) and institutional practices that replicate inequities over separations of time and space are required. We contend that both conditions that produce inequities in access and the conditions that produce inequities in health outcomes are important dimensions as an arena for nursing action.

Revision date: 3/24/20

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